The War on TB

Context:
According to recently published WHO’s Global Tuberculosis Report 2017, India
stood out as a country in which the budget envelope for TB was substantially
increased in 2017 (to US$ 525 million, almost double the level of 2016).
Report also mentioned political commitment from the Prime Minister to the goal of
ending TB by 2025. The budget is fully funded, including US$ 387 million (74%)
from domestic sources (triple the amount of US$ 124 million in 2016) and the
remainder (26%) from international donor sources.
Global tuberculosis report
WHO has published a global TB report every year since 1997.
 The main aim of the report is to provide a comprehensive and up-to-date
assessment of the TB epidemic, and of progress in prevention, diagnosis and
treatment of the disease at global, regional and country levels.
 This is done in the context of recommended global TB strategies and targets
endorsed by WHO’s MemberStates and broader development goals set by the
United Nations.
For the period 2016–2035, these are WHO’s End TB Strategy and the United Nations’
(UN) Sustainable Development Goals (SDGs), which share a common aim: to end the
global TB epidemic.
Why is Tuberculosis a major cause of concern?
TB is the ninth leading cause of death worldwide and the leading cause from a single
infectious agent, ranking above HIV/AIDS.
 TB is an infectious disease caused by the bacillus Mycobacterium tuberculosis.
 It typically affects the lungs (pulmonary TB) but can also affect other sites.
 The disease is spread when people who are sick with pulmonary TB expel
bacteria into the air, for example by coughing.
 Broader influences on the TB epidemic include levels of poverty, HIV infection,
under nutrition and smoking.
 Diagnostic tests for TB disease include – Rapid molecular test, Sputum smear
microscopy, Culture-based methods
 Without treatment, the mortality rate from TB is high.
Drug-resistant TB(MDR-TB) has been a continuing threat.
 The bacteria that cause tuberculosis (TB) can develop resistance to the
antimicrobial drugs used to cure the disease.
 Multidrug-resistant TB (MDR-TB) is TB that does not respond to at
least isoniazid and rifampicin, the 2 most powerful anti-TB drugs.
 In 2016, there were 600 000 new cases with resistance to rifampicin (RRTB) of
which 490 000 had multidrug-resistant TB (MDR-TB).
 Globally, the TB mortality rate is falling at about 3% per year. TB incidence is
falling at about 2% per year.
Most high TB burden countries have major challenges ahead to reach SDG targets
related to these and other determinants.
Strategies to end TB
From 2000 to 2015, global and national efforts to reduce the burden of tuberculosis
(TB) disease were focused on achieving targets set within the context of the
Millennium Development Goals (MDGs) established by United Nations.
In 2016, the MDGs were succeeded by a new set of goals, known as the Sustainable
Development Goals (SDGs).
 The consolidated goal on health is SDG 3. One of these targets, (Target 3.3),
explicitly mentions TB.
 SDG 3 also includes a target (Target 3.8) related to universal health coverage
(UHC) in which TB is explicitly mentioned. This includes an indicator on the
coverage of essential prevention, treatment and care interventions.
 Emphasis is also given to the importance of death registration within national vital
registration systems for accurate tracking of causes of death (WHO Global Task
Force on TB Impact Measurement).
 The End TB Strategy
 The overall goal is to “End the global TB epidemic”, and there are three high-
level, overarching indicators and related targets and milestones.
 The three indicators are: the number of TB deaths per year; the TB incidence rate
per year; and the percentage of TB-affected households that experience
catastrophic costs as a result of TB disease.
 The 2035 targets are a 95% reduction in TB deaths and a 90% reduction in the TB
incidence rate, compared with levels in 2015.
 The 2030 targets are a 90% reduction in TB deaths and an 80% reduction in the
TB incidence rate, compared with levels in 2015
 Two new TB drugs, bedaquiline and delamanid, have already received
accelerated or conditional regulatory approval based on trial results and is now in
next stage trials.
Achieving these targets requires,
 Provision of TB care and prevention within the broader context of universal
health coverage,
 multi-sectoral action to address the social and economic determinants and
consequences of TB
 Technological breakthroughs by 2025 so that incidence can fall faster than rates
achieved historically.
Key facts about the status of TB in India as per Global tuberculosis report, 2017
India registered a slight drop in the number of new tuberculosis cases and TB
deaths in 2016 compared with 2015.
 From an estimated 2.84 million new cases in 2015, the number dropped
marginally to 2.79 million in 2016, according to the World Health Organisation’s
Global tuberculosis report, 2017.
 In terms of mortality, the drop was from 0.51 million in 2015 to 0.43 million in
2016. The number of deaths and the incidence rate have been falling both globally
and in India.
 With 1.7 million new cases in 2016, India still continues to be the largest
contributor to the global burden with up to a quarter of the 6.3 million new cases
of TB (up from 6.1 million in 2015).
 Funding Source: 74% domestic funding and 26% international funding.
 More men above the age of 15 suffer from TB than women.
What are the present issues concerning regarding TB in India?
The government has committed to achieve a ‘90-90-90 target’ by 2035 (90%
reductions in incidence, mortality and catastrophic health expenditures due to TB).
This is premised on improved diagnostics, shorter treatment courses, a better vaccine
and comprehensive preventive strategies.
 However, much work remains to improve case notifications as only 1.9 million
TB cases in the public and private sectors were notified in 2016, leaving a 25%
gap between incidence and notification, the largest in the world.
 Though notification was made mandatory in 2012, multiple surveys and
surveillance data still show large under-reporting of detected TB cases, especially
in the private sector.
 Top-line drugs are still inadequate to treat people who suffer from the drug-
resistant forms of the disease.
 The number of estimated multi-drug-resistant TB cases increased marginally to
84,000. But the number of people with MDR-TB enrolled for treatment improved
marginally between 2015 and 2016.
 For the first time, steps have been taken to offer preventive TB treatment to a
small (5%) number of people who are HIV-positive, and 1.9% of children below
five years who are household contacts of people recently diagnosed with
pulmonary TB.
 Notably, domestic funding (74%) for anti-TB work has been more than that from
international sources (26%).
 The surveillance systems remain inadequate.
What should be done to achieve the set targets under End TB strategy?
The targets set in the End TB strategy are global reduction of 20% in incidence and
35% in mortality by 2020, taking 2015 as the base year.
 To reach that target, the global drop in incidence has to be 4-5% a year —
currently it is about 2% a year.
 The percentage of deaths should come down from the current 16% to 10%.
 With India accounting for the highest TB incidence (23%) and mortality (26%)
globally, success in realising the End TB targets hinges largely on the country
strengthening its systems.
 The major step in defeating the disease and achieving the targets is to record
every diagnosed patient through case notification.
 When a person is diagnosed with TB, it is reported to the national surveillance
system, and then on to the WHO.
 While better funding might help India inch closer to its stated goal of ending TB
by 2025, much more is needed in terms of funding and commitment on all fronts.
Way forward
The pipelines for new diagnostics, drugs, treatment regimens and vaccines are
progressing, but slowly. Increased investment in research and development is needed
for there to be any chance of achieving the technological breakthroughs needed by
2025.
The WHO Global Ministerial Conference on ending TB in the SDG era in November
2017 and the first UN General Assembly high-level meeting on TB in 2018 provide a
historic opportunity to galvanize the political commitment needed to step up the battle
against TB and put the world and individual countries on the path to ending the TB
epidemic.